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Fungal infections complicating tumor necrosis factor alpha blockade therapy

Sotirios Tsiodras1, George Samonis, Dimitrios T Boumpas

  • 14th Academic Department of Internal Medicine and Infectious Diseases, Attikon University General Hospital, University of Athens Medical School, Greece.

Mayo Clinic Proceedings
|February 5, 2008
PubMed

Insights

Tumor necrosis factor alpha (TNF-alpha) blockade therapy can lead to serious invasive fungal infections (IFIs). Prompt medical attention is crucial as these infections can be severe and fatal, necessitating vigilant patient monitoring.

Area of Science:

  • Immunology
  • Infectious Diseases
  • Pharmacology

Background:

  • Tumor necrosis factor alpha (TNF-alpha) blockade is a key therapy for autoimmune and inflammatory conditions.
  • Invasive fungal infections (IFIs) are a rare but serious complication of TNF-alpha inhibition.
  • Understanding the spectrum and outcomes of IFIs associated with anti-TNF-alpha agents is critical for patient safety.

Purpose of the Study:

  • To investigate the incidence, characteristics, and outcomes of invasive fungal infections (IFIs) in patients receiving TNF-alpha blocking agents.
  • To identify risk factors and common fungal pathogens associated with TNF-alpha inhibitor therapy.
  • To provide recommendations for clinical suspicion and management of IFIs in this patient population.

Main Methods:

  • A comprehensive literature search of MEDLINE and PubMed databases was conducted for reports of IFIs linked to infliximab, etanercept, and adalimumab from 1966 to 2007.
  • Data on patient demographics, specific anti-TNF-alpha agents used, time to IFI diagnosis, co-administered immunosuppressants, fungal species, infection patterns, and outcomes were extracted and analyzed.
  • Statistical analysis included descriptive statistics to summarize the findings.

Main Results:

  • Out of 281 reported IFIs, 80% were associated with infliximab, 16% with etanercept, and 4% with adalimumab.
  • The most common IFIs were histoplasmosis (30%), candidiasis (23%), and aspergillosis (23%), often presenting as pneumonia.
  • Nearly all patients (98%) received concomitant immunosuppressants, primarily corticosteroids. Mortality was 32% among cases with available outcome data.

Conclusions:

  • TNF-alpha blockade is associated with a significant risk of invasive fungal infections across diverse patient groups.
  • A high index of suspicion for IFIs is essential in patients on TNF-alpha antagonists due to potentially fulminant disease courses.
  • Prospective registries are recommended for surveillance of IFIs complicating TNF-alpha blockade and other biologic therapies.

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